An Unusual Presentation and Etiology of Hypotension Seen in Nephrotic Syndrome


Anna-Maria Panagiotides, MD; Aviv Hever, MD; John J Sim, MD

Spring 2009 - Volume 13 Number 2

Objective and Clinical Importance

An unusual clinical case of hypotension and acute kidney injury seen in a patient with underlying nephrotic syndrome is presented with an emphasis on understanding the differential diagnosis as well as the pathophysiology of the underlying disease.

Case History

A woman, age 58 years, reported having experienced presyncopal dizziness for two weeks. During her physical examination, her systolic blood pressure was found to be approximately 70 mm Hg. She reported that for two weeks, she had taken 20 mg of furosemide daily for lower-extremity edema. She said that she had not had any chest pain, palpitations, shortness of breath, fever, or hypothermia and did not have any history of bleeding, diarrhea, polydipsia, dysuria, seizures, or abdominal pain. She did exhibit gastrointestinal symptoms of nausea and early satiety as well as urinary symptoms of polyuria and nocturia. Her medical history included hyperlipidemia and rheumatoid arthritis. She had no history of diabetes, liver disease, or cardiac disease. She had at one time undergone a hysterectomy and an appendectomy. She reported that she did not use tobacco, alcohol, or street drugs. Her prescribed daily dosages of oral medications included 20 mg of furosemide; 20 mg of simvastatin; 20 mg of omeprazole; 40 mg of benazepril; 200 mg of Oysco 500; and hydrocodone-acetaminophen, which she had been taking for several months. She was not taking any disease-modifying agents for her rheumatoid arthritis. Her vital signs were as follows: blood pressure, 70/30 mmHg; temperature, 98.6°F (37°C); pulse rate, 96 beats per minute; respiration rate, 18 breaths per minute; oxygen saturation, 99%; weight, 75 kg. The physical examination demonstrated bilateral 2+ pedal edema, several bruises on her back and legs, and right-eye subconjunctival hemorrhage. Jugular venous pressure was not elevated, and there were no rales. The patient did not have any joint deformities. The patient had negative results on guaiac testing.



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